Infliximab Infusion (Page 1 of 2)

Patient Name: _________________ Provider Orders for: DOB: ________________ InFLIXimab Infusion (Page 1 of 2) = must check off to order / automatically initiated unless crossed out Date: ____________ Time: _________ Weight _______kg Height: _______cm BSA: __________ Diagnosis: Crohn’s disease Ulcerative colitis Plaque psoriasis Psoriatic arthritis Rheumatoid arthritis Ankylosing spondylitis PPD Date: ____________ Result: __________ Chest X-Ray Date: _______ Result: __________ Infusion: Inflectra (Drug of choice) Remicade (Non-formulary – Provider must complete a formulary request form) Infusion Frequency: One time only Three visits (Day 0, 2 Weeks, 6 Weeks) Maintenance infusion every _____ weeks until _______ (STOP DATE) Vital Signs: Prior to infusion, at every rate increase, and completion Notify Physician if: Systolic BP less than 90 mmHg or greater than 160 mmHg and/or Pulse less than 60/minute or greater than 120/minute and/or Temperature greater than 38.3 C (101 F) For reactions to inFLIXimab STOP INFUSION and initiate Anaphylactic Reaction Med-Induced Physician Orders – (Form #83EANAPX) Supportive Medications: acetaminophen (Tylenol) 650 mg PO Before inFLIXimab dexamethasone (Decadron) 10 mg or 20 mg IVPB or PO Before inFLIXimab diphenhydrAMINE (Benadryl) 25 mg or 50 mg IVPB or PO Before inFLIXimab Other Medications: __________________________________________________________ ___________________________________________________________________________ IV Line Patency Maintenance: NS IV 250 mL at 30 mL/hr during infusion Flush central line with 5 mL heparin 100 units/mL IV Other Orders: ____________________________________________________________________ ________________________________________________________________________________ _________________________, RN _____________________, MD (Nurse Signature) (Physician Signature) 83EINFLI 02/18 Patient Name: _________________ Provider Orders for: DOB: ________________ InFLIXimab Infusion (Page 2 of 2) = must check off to order / automatically initiated unless crossed out InFLIXimab Treatment Order Drug Dose Total Daily Route Dose IVPB in NS (see protocol below) inFLIXimab 3 mg/kg _______ mg (final concentration to be between 0.4 to 4 mg/mL) IVPB in NS (see protocol below) inFLIXimab 5 mg/kg _______ mg (final concentration to be between 0.4 to 4 mg/mL) IVPB in NS (see protocol below) inFLIXimab __ mg/kg _______ mg (final concentration to be between 0.4 to 4 mg/mL) *Begin infusion within 3 hours of reconstitution. Pharmacy to adjust dose to patient current weight. Infuse with 1.2 Micron filter. Do Not infuse any other medication into line with inFLIXimab. *Flush line with NS before and after medication is administered. Initial Infliximab infusion per 90-minute (min) protocol *If tolerated, remaining doses to be infused using 60-minute (min) protocol *IF any infusion reactions, use standard 2 hour protocol Standard Infliximab Accelerated Infliximab Infusions Infusions *Rates for total volume of 250 mL* ^Rates for total volume of 500 mL^ *250mL, 120 min *250mL, 90 min *250mL, 60 min ^500mL, 90 min ^500mL, 60 min Infusion Rates Infusion Rates Infusion Rates Infusion Rates Infusion Rates 10 mL/hr x 15 min 10 mL/hr x 15 min 20 mL/hr x 8 min 20 mL/hr x 15 min 50 mL/hr x 8 min 20 mL/hr x 15 min 20 mL/hr x 15 min 40 mL/hr x 8 min 40 mL/hr x 15 min 100 mL/hr x 8 min 40 mL/hr x 15 min 40 mL/hr x 15 min 80 mL/hr x 8 min 80 mL/hr x 15 min 350 mL/hr x 8 min 80 mL/hr x 15 min 80 mL/hr x 15 min 160 mL/hr x 8 min 300 mL/hr x 8 min 500 mL/hr x 8 min 150 mL/hr x 30 min 500 mL/hr until done 300 mL/hr x 15 min 700 mL/hr until done 750 mL/hr until done 250mL/hr until done 550 mL/hr until done Protocols produced for standard and accelerated Infliximab infusions Supporting Study: McConnell J, et al. World Journal of Gastrointestinal Pharmacology and Therapeutics. 2012; 3(5): 74-82 PubMed Central 2015. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3602441 _____________________, RN _____________________, MD (Nurse Signature) (Physician Signature) 83EINFLI 02/18 .

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